Should accredited continuing medical education providers for integrative medicine be prohibited from training medical doctors to practice integrative modalities that aren’t “generally accepted within the profession of medicine as appropriate for the care of patients”? What impact might this have on efforts – for instance – to shift chronic pain treatment toward non-pharmacologic approaches that most of medicine doesn’t “generally” include? Might giving arbiters of science in a disease model this power put the brakes on efforts to shift clinical care from managing disease to creating health? These other significant questions are on the table for the integrative health field as the Accreditation Council for Continuing Medical Education (ACCME) posts its draft revision of accreditation standards. The changes, targeting issues throughout CME, have particular challenges for the integrative medicine field. The comment period closes February 21, 2020.
From “continuing medical education” to “accredited continuing education”
The ACCME proposals have two major areas of concern for the integrative and functional medicine communities. One relates to conflict of interest. I will explore this in a follow-up column. The other, and most significant, is that referenced above. The ACCME calls it “content validity”. This includes both clarity on the quality of science behind all statements and an additional startling prohibition on teaching practitioners how to practice new complementary and integrative modalities that are not “generally accepted”. In short, integrative medicine CME providers can’t teach practitioners how to “do” anything that is not stamped first as “generally accepted.”
Before exploring this, it may be useful to note that these proposals for changed guidelines come amidst two quietly powerful language changes. Both reside in the ACCME proposal to use a new rubric to describe their stock in trade. In place of the historic “continuing medical education” (CME) they are using “accredited continuing education” (ACE). The first change is the titular highlighting of their work of “accreditation.” The brand of “CME” no longer will say what is necessary. The other is the dropping of “medical” from the phrase. Is the intent to be to not preclude influence over offerings to other fields? Each is worth noting, and tracking.
“Generally accepted” in a context fraught with ignorance
The proposed “Standard 1: Ensure Content is Valid” includes the following new language:
1.4 Accredited education may inform learners about approaches to diagnosis or treatment that are controversial or not generally accepted but must not include advocacy for these approaches or teach healthcare professionals how or when to use them. (italics added)
In an environment in which most conventional medical practitioners still receive little to no required education about complementary and integrative practices – despite their inclusion in multiple governmental and quasi-governmental guidelines – the bar of “generally accepted” raises reasonable concerns. Will decisions be made by ACCME officials who may remain essentially ignorant to the actual science that exists?
Such concern can have additional animus. That professors of medicine in leading academic medical centers continue to trumpet the idea that acupuncture doesn’t work and that the integrative enterprise is “quackademic medicine” reasonably adds a dimension of paranoia to the reliance on “general” perspectives. Will integrative practices get a fair shake?
The prior three guidance points in the proposed standard don’t relax these concerns:
1.1 All recommendations involving clinical medicine in accredited education must be scientifically justified and generally accepted within the profession of medicine as appropriate for the care of patients.
1.2 Accredited education must give a fair and balanced view of diagnostic and therapeutic options.
1.3 All scientific research referred to, reported, or used in accredited education in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, and analysis.
An interview for this series with Rick Hecht, MD, chair of the Academic Consortium for Integrative Medicine and Health, Hecht offers assurances that the ACCME may be expected to be respectful toward the science supporting integrative practices. The interview reports Hecht’s view of a phone conference with ACCME president and CEO Graham McMahon, MD, MMSc that Hecht had with Francoise Adan, MD, the Consortium’s chair-elect, and Dale West, Consortium executive director.
“Controversial topics” – and tending to integrative medicine’s own evidence gardens
It is not that presenters of integrative medicine CME cannot strengthen their relationships to existing science. Often, in a desire to underscore the existence of scientific support, practitioners may overstate the nature of referenced research. This can take many forms. For instance:
These are real and fixable through greater rigor from presenters, more clarity on instructions from CME providers – and more research.
Yet the requirement for “general acceptance” denies a more significant scientific collision with the ACCME and mainstream scientific thinking. The American College of Lifestyle Medicine (ACLM) recently proposed a strategy to cross the chasm. The ACLM’s Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM) counters the way – in ACCME’s language – “generally accepted standards of experimental design, data collection, and analysis” in systematic reviews are biased toward randomized controlled trials (RCT) and against epidemiological and other data that strongly support lifestyle interventions. “Generally accepted” has a fist on the scale toward pharma.
Another example of the way clashing scientific paradigms make “generally accepted” a poor threshold is that integrative clinicians may argue that, if agents or practices are known to be safe, then a lower level of science compared to that for pharma with high adverse events profiles should be acceptable. Has the ACCME bought this view? Integrative practitioners may further use a handful of such therapies in addressing the full body-mind. While each may have a relatively low level of evidence, they may assert that together, in their “whole system” approach, these boost each other’s effects as they seek to assist a patient toward health. The low level of investment in “whole systems research” at the NIH National Center for Complementary and Integrative Health (NCCIH) and elsewhere has meant that limited evidence is available to support such an argument should a case be made, for instance, to ACCME. Does this bury CME – or rather, “ACE” – for clinicians seeking to convert to this whole person, patient-centered practice models?
In an interview on HEALM, ACLM’S lead investigator David Katz, MD, MPH decried the “tyranny of the RCT” as an obstacle, ultimately, to health. Will the ACCME’s proposals more deeply lock down such tyranny against those seeking to break out of it? Clearly, a challenge to what is “generally accepted” suggests the importance of engaging the ACCME on why judging the integrative new based on old and reductive, disease-reactive paradigm thinking is an obstacle to health.
Background interviews and discussion informing this column have made clear that the ACCME’s proposed standard for “content validity” has many CME providers in the integrative health space on alert. Over the past two years, perhaps the most significant, under-reported story in integrative medicine is a series of ACCME actions challenging CME practices of entities offering content on integrative medicine practices.
Over the past 25 years, the relatively open access to ACCME-approved educational opportunities for medical doctors who are interested in shifting their practice toward more patient-centered, health-focused and integrative models has fueled the growth of the integrative medical movement. Those working in hospitals and academic centers, have been able to use CME travel and conference stipends in their employment contracts to learn both about, and how to use, integrative approaches at ACCME-approved integrative medicine events.
The ACCME’s concern about “controversial approaches” has bigger fish to fry than integrative approaches. Concerns may be over a new yet poorly researched orthopedic procedure with a much higher risk, or sessions on off-label uses of drugs. Yet integrative medicine is clearly in their sights. Will this chill the transition of medical doctors toward more integrative models? For those prone to paranoia, the concurrence of the ACCME’s new push with Google’s claim that scientific overclaims are behind its significant restriction of access to consumer sites for natural health and integrative content can seem eerie. Each has in common the bottom lines: they call to the integrative field for clarified standards, for relationship building, and for self-advocacy.
Next: Part 2 – Proposed changes relative to conflicts of interest.